Videothoracoscopic identification of chondromatous hamartoma of the lung.

0.09 MB·English

by  Bohanes, Tomas

Original paper Videosurgery
Videothoracoscopic identification of chondromatous hamartoma
of the lung
TToommáášš BBoohhaanneess11,, MMaarreekk SSzzkkoorruuppaa11,, JJiiřříí KKlleeiinn11,, ČČeessttmmíírr NNeeoorraall11,, JJaannaa ZZaapplleettaalloovváá22,, JJoosseeff CChhuuddááččeekk11,, KKaatthheerriinnee VVoommááččkkoovváá11,,
RRaaddeekk VVrrbbaa11
1The First Department ofSurgery, Palacký University Teaching Hospital, Olomouc, Czech Republic
2Department ofMedical Biophysics, Palacký University Faculty ofMedicine and Dentistry, Olomouc, Czech Republic
Videosurgery Miniinv 2013; 8 (2): 152-157
DOI: 10.5114/wiitm.2011.33013
Abstract
IInnttrroodduuccttiioonn:: Themain disadvantage ofavideothoracoscopic procedure is thelack oftouch sensation. Theprobabili-
ty ofeasily finding thelesion is usually estimated according to computed tomography (CT).
AAiimm:: To find useful parameters oflocation ofchondromatous hamartoma ofthelung parenchyma in relation to its
size to assess theprobability ofsuccessful search via avideothoracoscopic approach only.
MMaatteerriiaall aanndd mmeetthhooddss:: Agroup of55 patients operated on for chondromatous hamartoma ofthelung at theFirst
Department ofSurgery in Olomouc from January 2006 to June 2011 was analyzed. Initially, thetumor’s longest diame-
ter and its nearest distance to thepleural surface were measured on CT scans. Subsequently, thesurgery began using
thevideothoracoscopic approach. Ashort thoracotomy with direct palpation followed when videothoracoscopy failed.
RReessuullttss:: No significant differences in age, sex and side oflocalization between thegroup with and without successful
videothoracoscopic detection were found. A significant difference was found in the median size (p = 0.026) and
thedepth ofthetumor (p < 0.0001) and in thecalculated index “tumor size/depth” (p < 0.0001). Deeper analysis
revealed that theparameters “depth” and “index size/depth” are considered to be good predictors but theparame-
ter “size” is not asuitable predictor.
CCoonncclluussiioonnss:: Themain predictors ofsuccessful videothoracoscopic detection oflung chondromatous hamartoma are
considered to be the depth of the tumor in the lung parenchyma with a cut-off value ≤ 7.5 mm and the index
“size/depth” with acut-off value ≥1.54; the tumor size is not considered to be agood predictor.
KKeeyy wwoorrddss:: chondromatous hamartoma, lung, videothoracoscopy, video-assisted thoracic surgery, pulmonary nodule.
conditions where it plays avery important role [2-6].
Introduction
The benefit of this minimally invasive approach for
The technique of thoracoscopy was introduced thoracic surgery patients is obvious; reduction ofpain
by Jacobaeus in 1910, primarily for the diagnostics and cosmetic effect are themost frequently reported
ofpleural and pulmonary diseases [1]. Since that time improvements [7, 8]. On the other hand, the afore-
significant advances in surgical equipment, endo- mentioned pain relief remains controversial accord-
scopic stapling devices, video monitoring and endo- ing to other studies [9].
scopic surgical techniques have expanded the role The main disadvantage of such a videothoraco-
of thoracoscopy in many intrathoracic pathologic scopic procedure is thelack oftouch sensation during
Address for correspondence
Čestmír Neoral MD, CSc, First Department ofSurgery, Palacký University Teaching Hospital Olomouc, I.P. Pavlova 6, 77520 Olomouc,
Czech Republic, phone: [phone], e-mail: [email protected]
152 VideosurgeryandOtherMiniinvasiveTechniques2,June/2013
Videothoracoscopic identification ofchondromatous hamartoma ofthelung
theprocedure. However, direct palpation in detection most cases, it may be done employing only the
of occult nodules in the lung parenchyma can be minimally invasive approach provided that we can
vital, especially when lesions are located deeper in find the mass in the lung parenchyma without
the tissue and they are smaller. In almost all guide- direct palpation ofthelung.
lines and textbook descriptions ofvideo-assisted tho- Theprobability offinding thelesion without direct
racic surgery procedures (VATS) for lung nodules, touch is usually estimated by asurgeon according to
direct palpation is considered to be an essential ele- theevaluation ofCT findings. Nonetheless, this kind
ment oftheprocedure, but it requires ashort thora- of estimation is very subjective and requires exten-
cotomy for insertion of one or several fingers into sive experience.
the patient’s chest. This is certainly more invasive
than simple videothoracoscopy with only punctures Material and methods
for insertion oftrocars and it is against thecontem-
To try to find a more objective approach to
porary trend to reduce the surgery trauma as much
theissue, theauthors prospectively studied agroup
as possible [10]. That is why several methods of
ofpatients operated on for this diagnosis at theFirst
marking thenodule site for asubsequent video thora-
Department of Surgery, Palacký University Hospital
coscopic procedure were introduced, e.g. injection
Olomouc from January 2006 to June 2011. Astandard
ofdye [11] or application ofahook wire under com-
protocol was used in all of these patients. Patients
puted tomography (CT) control [12] or perioperative
with suspicion of chondromatous hamartoma were
ultrasonography [13].
indicated for surgery. Prior to theoperation, thetu m-
Among typical indications for such a minimally
ors were measured on CT scans and the longest
invasive procedure in the chest are chondromatous
diameter and nearest distance to thepleural surface
hamartomas. Pulmonary chondromatous hamar-
were recorded.
toma (PCH) is defined as abenign tumor which orig-
inates from the mesenchymal cells associated with The surgery always began using the videothora-
the bronchial and bronchiolar walls. It is composed coscopic approach and was performed under selec-
of mature and immature chondroid tissue, adipose tive ventilation ofthecontralateral lung. Trocar place-
tissue, osteoid and smooth muscle cells in various ment was determined according to location of the
amounts and ratios. Epithelial elements such as tumor. Asurgeon revised thepleural cavity to exclude
bronchial and bronchiolar epithelium, type II pneu- other pathology and then tried to locate the tumor
mocytes and rarely bronchiolar glands may also by inspection and with “palpation” using an endo-
be present in chondromatous hamartomas [14-16]. scopic instrument with or without a tampon. In
Apathogenetic relationship between PCH and lipoma the hands of an experienced thoracic surgeon, this
and leiomyoma is obvious whereas the progenitor “palpation” method was able to reveal deeply located
mesenchymal cell situated in thebronchial wall may tumors within the collapsed lung. When the tumor
differentiate along chondroid, adipose and smooth was located, its enucleation via the videothoraco-
muscle. It has also been demonstrated that epithelial scopic approach followed with cutting ofthevisceral
proliferation in PCH is reactive and closely associated pleura and parenchyma and removal of the tumor
with neoplastic proliferation of the mesenchymal through this pulmotomy, which was finally sutured
component [16]. with a stitch. When videothoracoscopic search with
Lung hamartomas are generally indicated for instrument-only “palpation” failed, a short thoraco-
removal. Primarily, sarcomatous transformation in tomy was performed by enlarging one of the previ-
a long-standing, clinically silent hamartoma has ous incisions so that it would be possible to insert
been reported [17]. Secondly, it may sometimes be one or more fingers into thepleural cavity for direct
difficult to differentiate benign hamartomas from palpation ofthelung tissue. In several patients peri-
other primary and secondary tumors ofthelung or operative ultrasound was employed in case offailed
other lesions such as tuberculoma etc. solely simple videothoracoscopic search as part ofanother
according to imaging examinations. Moreover, it is research, but this did not influence the results
usually relatively easy to find and enucleate these ofthedescribed study. After tumor detection, surgery
cartilaginous rounded masses from the lung pa- followed as in the previous case, unless the tumor
renchyma with minimal injury to the tissue. In was located too deep or in thevicinity ofsome main
Videosurgery and Other Miniinvasive Techniques 2, June/2013 153
Tomáš Bohanes, Marek Szkorupa, Jiří Klein, Čestmír Neoral, Jana Zapletalová, Josef Chudáček, Katherine Vomáčková, Radek Vrba
vessels. In this situation it was necessary to finish using thesoftware SPSS version 15 (SPSS Inc., Chica-
the procedure through a short thoracotomy. Five go, USA). Thecategorical parameters were compared
patients were excluded from the study group when by means of the χ2 test or Fisher’s exact test.
theperioperative finding was different from thepre- TheMann-Whitney Utest was used to compare con-
supposed diagnosis of chondromatous hamartoma tinuous parameters. The normality of distribution
(carcinoid, tuberculoma, metastasis) because ofthe- was checked by theShapiro-Wilk test. Logistic regres-
oretically different touch feeling in these nodules sion analysis and receiver operating characteristics
(they are usually softer and less circumscribed, which (ROC) analysis were used to identify suitable predic-
may bias theresults) and those procedures were fin- tors of probability of videothoracoscopic detection
ished according to thefinding. ofthetumor. All tests were performed at thesignifi-
Theobtained data ofpreoperative measurements cance level of0.05.
and results of detection during the procedure were
analyzed statistically. The goal was to find parame- Results
ters oftumor location within thelung parenchyma in
During the study period, the conditions deter-
relation to its size allowing assessment oftheproba-
mined to be evaluated in thestudy were fulfilled in
bility ofsuccessful search ofthetumor via thevideo-
55 patients (29 males, 26 females). No significant dif-
thoracoscopic approach without theneed to enlarge
ferences in age, sex and side oflocalization between
theincision and with no special technique employed
thegroup with successful videothoracoscopic finding
for its detection. Thedata were statistically analyzed
ofthetumor and without were found (Table I).
The groups of patients were analyzed as to the
TTaabbllee II..Characteristics ofthegroup ofpatients
location of the tumor in specific segments of the
VVaarriiaabbllee TTSS ++ ((nn== 2266)) TTSS –– ((nn== 2299)) VVaalluuee ooffpp lungs. In both groups themost frequent occurrence
Age 54.5 56.0 0.637a was found in segment 3 (38.5%/20.7%). No signifi-
cant difference was found using Fisher’s exact test
(48.5-59.8) (50.0-65.0)
(p= 0.485) (Figure 1).
Sex (M/F) 14/12 15/14 0.875b
Analysis found statistically significant differences
(53.8%/46.2%) (51.7%/48.3%)
in the most expected values, i.e. in median tumor
Side (L/R) 9/17 10/19 0.992b size, depth of the tumor location, and the index
(34.6%/65.4%) (34.5%/65.5%) tumor size/depth of location, confirmed by the
Mann-Whitney Utest (Table II).
Median (25th-75thpercentile), aMann-Whitney Utest, bχ2test
50
40 38.5
ee 30
gg
aa
nntt 23.1
ee
cc 20.7
PPeerr 20 17.2 17.2
11.5
10.3 10.3
10 7.7 6.9 6.9 6.9
3.4 3.8 3.8 3.8 3.8 3.8
0 0
0
1 2 3 4 5 6 7 8 9 10
SSeeggmmeenntt NNoo..
TS + TS –
FFiigguurree 11.. Distribution of the tumors in the lung segments
154 Videosurgery and Other Miniinvasive Techniques 2, June/2013
Videothoracoscopic identification ofchondromatous hamartoma ofthelung
The median size of the tumor in the detectable TTaabbllee IIII.. Results of analysis of size and depth
group was 15 mm (min-max: 8-45 mm), in theunde- ofthetumor and index size/depth
tectable group 10 mm (6-40 mm) (p = 0.026). The
VVaarriiaabbllee TTSS ++ ((nn== 2266)) TTSS –– ((nn== 2299)) VVaalluuee ooffpp
tumors in the detectable group were located more
Size [mm] 15.0 (10.8-20.0) 10.0 (9.0-14.5) 0.026a
superficially, with median depth of5 mm (0-10 mm),
than those in the undetectable group, with 12 mm Depth [mm] 5.0 (0.0-6.0) 12.0 (8.5-22.5) < 0.0001a
(3-52 mm) (p< 0.0001). Theindex tumor size/depth
Size/depth 3.4 (2.5-92.5) 0.8 (0.5-1.4) < 0.0001a
was calculated and was different in the two groups
(3.4/0.8) (p< 0.0001). Data are expressed as median (25thand 75thpercentile), aMann-Whitney
Utest
Discussion
and 0.931. In contrast, the parameter “size” is not
The probability of successful videothoracoscopic asuitable predictor with AUC of 0.674 (Figure 2). Opti-
detection ofalung lesion is certainly quite acomplex mal cut-off values of the important predictors are
matter. It is possible to employ various special preop- shown in Table III. Similar cut-off values were pre-
erative or perioperative techniques which are able to sented by Tamura et al., with their values of> 10 mm
facilitate thedetection ofan occult tumor. Nonethe- in depth and < 15 mm in diameter [13], although they
less, this increases the costs and these techniques conclude the cut-off value as “no chance” whereas
are also related to certain adverse effects. Therefore, our conclusion represents values of borderline
it may be profitable to assess several known param- ofgood probability ofsuccessful detection.
eters to estimate thenecessity ofsuch asophisticat- Arather similar approach was presented by Dem-
ed approach. Measurement of two easily available my et al. [19], who created three formulas for their
distances is certainly a simple method, which may similar group of patients, which calculate potential
“visibility”, “respectability” and overall “simplicity”
improve our knowledge before thestart oftheproce-
using thesame data ofdepth and size ofthetumor,
dure. In spite ofthis fact, there are not many studies
where their “visibility” is almost identical to our
which address this issue and offer aclear solution.
“index size/depth”. Our results show, however, that
Our results correspond well with the results of
Tamura et al.[18], who found asimilar relation ofsize
and depth of location to probability of successful
videothoracoscopic detection. However, if we analyze 1.0
the date more closely, we can find that not all of
these presented statistically significant results are
good predictors for assessment ofprobability ofsuc- 0.8
cessful detection ofthetumor. Application oflogistic
regression analysis to our data shows that only yy
thetumor size and index size/depth are suitable pre- ssiivviitt0.6
nn
dictors in comparison to the size itself. Increase SSee
ofthevalue oftheindex size/depth by 1 is related to 0.4
a decrease in the chance of video thoracoscopy
detecting the tumor 0.571 times (95% CI for OR:
0.394-0.826, p = 0.003). Increase ofthetumor size by 0.2
1 mm means increase ofthechance ofdetection 1.11
times (95% CI: 1.001-1.232, p = 0.048). Subsequently,
0
this is confirmed by ROC analysis, which may also
0 0.2 0.4 0.6 0.8 1.0
show us values ofcut-off ofoptimal parameters for
SSppeecciiffiittyy
prediction ofchance ofvideothoracoscopic detection
Source of curve:
of the tumor. The parameters “depth” and “index
Size Size/depth Depth Reference line
size/depth” are considered to be good predictors
with values ofAUC (area under ROC curve) of0.899 FFiigguurree 22.. ROC curve
Videosurgery and Other Miniinvasive Techniques 2, June/2013 155
Tomáš Bohanes, Marek Szkorupa, Jiří Klein, Čestmír Neoral, Jana Zapletalová, Josef Chudáček, Katherine Vomáčková, Radek Vrba
TTaabbllee IIIIII.. Optimal cut-off values ofthemain predictors
VVaarriiaabbllee AAUUCC CCuutt--ooffff vvaalluuee SSeennssiittiivviittyy [[%%]] SSppeecciiffiicciittyy [[%%]] AAccccuurraaccyy [[%%]]
Depth oftumor location 0.899 ≤6.5 mm 84.6 82.8 83.6
≤7.5 mm 88.5 79.3 83.6
Index size/depth 0.931 ≥1.54 88.5 79.3 83.6
≥2.00 80.8 82.8 81.8
Size ofthetumor 0.674
such extensive calculations are not necessary, ing oftheintercostal space by atrocar and theneg-
though the mentioned paper showed a potentially ative influence of mechanics of ventilation is also
interesting and reliable way of tumor assessment. generally not substantial [9, 22]. In any case, if
More suitable for routine clinical use than Demmy’s detection of a tumor just by using videothoraco-
formulas is thelinear function (depth = 0.836 × size – scopic instrument-only “palpation” fails, apossibility
2.811) presented by Saito et al. [20]. Our index is the perioperative use of endoscopic ultrasound
“size/depth” with a cut-off value ≥ 1.54 produced examination, which may help localize the lesion
similar results in prediction ofsuccessful localization without the necessity of special preoperative man-
ofatumor, though, and it is easier to calculate. agement [23-25].
Detection ofan occult tumor may be specific to When we expect trouble in the detection of cer-
each individual. Sometimes the tumor location in tain occult lesions it is still possible to prepare
thevicinity ofamain bronchus or other structure can a patient for the procedure and employ a special
make this simple identification impossible. It also technique to label the tumor site. Under CT naviga-
requires extensive experience in minimally invasive tion it is possible to introduce a hook or a coil into
thoracic surgery because this videothoracoscopic the tissue adjacent to the tumor or into the tumor
“palpation” must be correctly interpreted in order to directly. Another possibility is to apply dye or radio-
recognize apathological finding from anormal one. tracer detected with radio-probe perioperatively. It
In our study this was not an issue because all proce- may increase the success in the detection of occult
dures were performed by experienced chest sur- lesions via the videothoracoscopic approach [12, 13,
geons with ahistory ofhundreds ofperformed mini- 24]; on theother hand, these methods are expensive
mally invasive thoracic procedures. and/or are related to some possible complications
When videothoracoscopic instrument-only detec- (mainly pneumothorax). Using radiotracer would also
tion of a lung nodule fails it does not mean clearly require special management of a patient due to
that it would be necessary to make astandard tho-
theuse ofaradioactive material.
racotomy. It is usually possible to simply increase
the size of one of the trocar incisions and insert
Conclusions
a finger through. With the assistance of an instru-
ment pushing thelung tissue against thefinger it is Evaluation of objective CT measurements may
possible to find themajority ofoccult lesions. In our help predict theprobability ofdetection ofchondro-
experience and in correlation with theresults ofoth- matous hamartomas or other occult lesions of the
er authors, the frequency of thoracotomies due to lung using the videothoracoscopic approach and as
the inability to find a lesion in another way is rela- such facilitate thedecision ofwhether it is necessary
tively low, and moreover, there are still some doubts to use a special technique instead. In our data,
as to whether it may significantly increase thesensi- the main predictors are considered to be the depth
tivity ofdetection ofoccult lesions [21]. Theclinical of the tumor location in the lung parenchyma with
impact ofan increase in incision length is not as sig- acut-off value ≤7.5 mm and theindex “size/depth”
nificant as it may seem. Pain is sometimes even with acut-off value ≥1.54. Thetumor size itself does
more intense after videothoracoscopy due to bruis- not seem to be agood predictor for this purpose.
156 Videosurgery and Other Miniinvasive Techniques 2, June/2013
Videothoracoscopic identification ofchondromatous hamartoma ofthelung
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